Provider Demographics
NPI:1487267266
Name:KENWORTHY, MARY LAREE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LAREE
Last Name:KENWORTHY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W FORT ST BLDG 88
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-4598
Mailing Address - Country:US
Mailing Address - Phone:208-422-1000
Mailing Address - Fax:208-422-1591
Practice Address - Street 1:500 W FORT ST BLDG 88
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4598
Practice Address - Country:US
Practice Address - Phone:208-422-1000
Practice Address - Fax:208-422-1591
Is Sole Proprietor?:No
Enumeration Date:2020-08-31
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID8104164W00000X
IDPN8104164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse